Establishing a Statewide Establishing a Statewide “Just Culture” for Patient Safety “Just Culture” for Patient Safety between Healthcare Providers between Healthcare Providers and Regulatorsand Regulators

2010 NCSBN Scientific SymposiumSeptember 26, 2010

Becky Miller, MHA, CPHQ, FACHEExecutive Director

Missouri Center for Patient Safetybmiller@mocps.org

MO-09-06-MOCPS

A Bit About the MOCPS• Statewide Not-for-profit• Founded by state medical association, hospital

association and QIO– Serve as a statewide PSO– Serve as a statewide resource center– Provide education and training– Facilitate statewide safety activities among broad

stakeholders

What does “just” mean to you?

• Fairness?• Right?• Equal?• Good?

What is a “Culture of Safety”

A culture of safety is an atmosphere of mutualtrust in which all staff members can talk freelyabout safety problems and how to solve them,without fear of reprisal.

Alternative Views of the Same Thing

The importance of culture“The single greatest impediment to

error prevention in the medical industry is that we punish people

for making mistakes” – Lucian Leape, Harvard School of

Public health

“It is through a Just Culture that we will begin to see, understand and mitigate the risks within the healthcare system”

– David Marx, Outcome Engineering

“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.”

- Don Norman, Apple Fellow

Definition: just (adjective) (from Dictionary.com) 1. Guided by truth, reason, justice, and fairness: We hope to

be just in our understanding of such difficult situations. 2. Done or made according to principle; equitable; proper: a just

reply. 3. Based on right; rightful; lawful: a just claim. 4. In keeping with truth or fact; true; correct: a just analysis. 5. Given or awarded rightly; deserved, as a sentence,

punishment, or reward: a just penalty.(others not listed)

What is a “Just Culture”

Definition: cul·ture (noun) (from Dictionary.com) 1. the quality in a person or society that arises from a concern for what is

regarded as excellent…. 2. a particular form or stage of civilization, as that of a certain nation or

period: Greek culture. 3. the behaviors and beliefs characteristic of a particular social, ethnic, or

age group: the youth culture; the drug culture. 4. Anthropology . the sum total of ways of living built up by a group of

human beings and transmitted from one generation to another. 5. the act or practice of cultivating the soil; tillage. (others not listed)

What is a “Just Culture”

The Model of a “Just Culture”?• Creating an open,

fair, and just culture• Creating a learning

culture• Designing safe

systems• Managing behavioral

choices

AdverseEvents

HumanErrors

Managerialand StaffChoices

SystemDesign

Learning Culture / Just Culture

The Just Culture Community; Outcome Engineering

The Problem Statement

Support of

System Safety

Blame-Free Culture

Punitive Culture

As applied to:• Providers• Managers• Institutions• Regulators

What system of accountability best supports system

safety?

A “Just Culture” Answers

The Just Culture Community; Outcome Engineering

• Two nurses select the wrong medication from the dispensing system. One dose is given to the patient, resulting in shock; the other is caught at the bedside before causing harm. How do we treat these nurses?

• A Phlebotomist loses custody of a yet-unlabeled specimen, but chooses not to report the incident, fearing discipline. Do we forgive his actions given his legitimate reason for the phlebotomist’s fear?

• An entire surgical team defends skipping the pre-surgical time-out because no adverse event occurred. Do we condone this policy violation?

• A nurse complains that a physician knowingly violated a safety rule, although it was broken in order to save a life. Do we condone the rule violation?

The Joint Commission Perspectives on Patient Safety, December 2009, Vol 9, Issue 12

Thinking from a “just culture” perspective...

The Missouri Story – The Why

• Seeking high impact, broad interest topic to introduce statewide

• Our champion - Missouri State Board of Nursing

• Training session desiring more

• Sought grant funding

The Missouri Story – The What

• Our Goals– To establish a more consistent understanding and

management of human error, at-risk behavior, and reckless behavior between Missouri healthcare providers and regulators

– Achieve an appropriate balance between a “blameless” culture and an “accountable” culture that supports patient safety improvement

The Missouri Story – The How• Steps in Our Collaborative

– Engaging key statewide stakeholders – September 2007– Recruitment of collaborators– Assessments of collaborator leadership teams (baseline)– Intervention

• Champion and team training• Ongoing support - one-on-one, teleconferences, Web site• On-site additional training

– Assessments post-intervention – Feedback from participants

The Missouri Story – The Who

• Our Team– Project Facilitator – MSN, PhD Candidate– Researcher – MSN, PhD– Data Analyst – QIO – Educator – Outcome Engineering, LLC– MOCPS Staff

Our Stakeholders

Key Stakeholders• Department of Health• Division of Professional

Registration• Department of Mental

Health• Missouri Hospital

Association• Missouri State Medical

Association• Missouri Organization of

Nurse Leaders

• Primaris (QIO)• Business Health Coalition• Health Systems• Missouri Nurses Association• College of Pharmacy• College of Nursing• Missouri Association for

Healthcare Quality

Medical errors are a national concern

Obligation of providers and regulators to hold individuals accountable for competency and behaviors

Goal to balance punitive and blame free cultures, maintaining accountability

Evaluation of behavior to determine human error, at-risk behavior, reckless behavior

Consideration of range of responses to safety events

Support for systems to enable safe behavior

Collaboration promoting continuous improvement, culture of safety

CollaboratorsType of organizationType of organization Geographic locationGeographic locationAcute care hospitals (42)Critical access hospitals (10)Regulatory

agencies/association(5)Home health (3)Long term care (1)Specialty hospitals (3)Physician offices (2)Professional school (1)

West (18) Central (18) South (12) East (19)

Collaborator Requirements• CEO Commitment Statement

Signed Letter of Support Allow Champion to actively and fully participate in training Identify a team of leaders to actively and fully participate

Champion C-Suite Physician leader Risk/Safety/Quality Human Resources

Use the concepts learned and continue to learn and utilize the concepts in an attempt to fully implement a “Just Culture”

Acknowledge opportunity to apply for additional consultation as part of the collaborative, grant funding support, and organization’s commitment of staff time and travel expense.

The Missouri Story – The Results• Assessments -

– Baseline and post-intervention to assess changes in understanding and use of Just Culture principles

• Modified the AHRQ Hospital Culture Survey– Maintained domains for national comparisons– Added 3 questions to incorporate “Just Culture” concepts– Phrased questions for leaders

• Structured interviews with non-provider participants• Feedback on collaborative, in general

Baseline Assessment• Most leaders believe staff are comfortable

reporting errors• Some acknowledge staff fear of retribution• Many believe staff only report errors that result in harm or

significant events

• Many leaders believe staff are mindful of errors around them, but not of near misses or unsafe conditions

• Most leaders believe they focus on system issues when responding to error; however

– Many look at the individual when an event occurs– Many indicate the response to an error depends on the scope and

severity of the error– Most feedback strategies focus on individual education and/or

counseling

Intervention – Number 1Champions Training

Intervention-Number 2 Regional Training• Team Training

– Our Beliefs About Managing Risk– The Role of System Design– Management of Human Error, At-Risk and Reckless Behavior– The Role of Event Investigation– The Just Culture Algorithm™

• Informational Teleconferences• Web Community• Regulator Round Tables• Board of Nursing – Complaint investigation session • Department of Health Managers Training Session

Intervention-Number 3 – Additional Training

• 27 Collaborative Participants• On site Consultation Options

– Executive briefings– Management team training– Staff training – Safe Choices for Staff™

• In total trained ~3,600 individuals

• All Perceptions Improved from Baseline– Teamwork Across Units (+8%)– Overall Perceptions of Patient Safety (+7%) – remains lower than

national– Communication Openness (+7%) – became higher than national– Frequency of Event Reports (+7%) – remains lower than national– Feedback & Communication about Error (+5%)– Teamwork within Units (+5%)– Supervisor/Management Expectations & Actions Promoting Pt. Safety

(+3%)– Organizational Learning-Continuous Improvement (+1.2%)– Non-punitive Response to Error (+1.2%)– Management Support for Patient Safety (< +1%)– Handoffs and Transitions (<+1%) – remains lower than national– Staffing (<+1%) - remains lower than national

Post-Intervention Assessment – Overall Results

Post-Intervention Assessment –Interesting Finding

• Active participation in the Missouri Just Culture collaborative– Created more awareness of patient safety issues

and culture by leaders at participating organizations.

– Moved leadership perceptions about patient safety and culture closer to staff perceptions from national survey.

CategoryLeast

EngagedMost

EngagedNational Leader

Response

National Staff

ResponseStaff feel free to question decisions or actions of those in authority.

100% 57% 68% 45%

Staff freely speak up when they see something that would negatively affect patient care.

100% 77% 83% 75%

When a mistake is made that could harm the patient, but doesn’t, how often is it reported?

100% 61% 78% 76%

My manager does not overlook safety problems that happen over and over.

100% 84% 85% 76%

Staff do not feel like their mistakes are held against them.

75% 59% 69% 50%

Management is interested in patient safety even when an adverse event hasn’t occurred.

75% 68% 75% 55%

Our procedures and systems are good at preventing error from happening.

100% 70% 77% 66%

Excerpt from - J Nurs Care Qual, 2010; “Influencing Leadership Perceptions of Patient Safety Through Just Culture Training” Vogelsmeier, Scott-Cawiezell, Miller, Griffith

What We’ve Learned

• There is widespread interest in Just Culture• Regulators are interested in working with providers on a Just

Culture• Opened discussions about to what extent

– Does leadership perception = staff perception?– Do we proactively seek safety improvement?– Do we look at system issues when errors occur?– Do staff fear retribution for reporting errors?– Does action depend on result of error vs. behavior choice?

• Education and interaction between leaders appears to narrow the gap between leader and staff perceptions of a safe culture– Leader perceptions from more actively engaged organizations were closer to

staff perceptions– Leaders indicated being more “in tune” with staff– Leaders believed staff were more mindful of error– Leaders indicated performing more in-depth investigations regardless of

level of harm incurred– Regulators improved understanding of provider issues– Regulators are interested in integrating concepts within their own processes

What We’ve Learned

• Barriers to implementing a Just Culture– Limited resources– No obvious return-on-investment to convince leadership– Limited commitment of administration and department heads– Resistance to new concepts– Staff turnover– Buy-in and support from Human Resources and front-line managers– Preconceived idea that punishment is the corrective action– Inconsistency among managers– Concern that blame and finger pointing will return

What We’ve Learned

“ Without the collaborative, I don’t know that we would be as far along with the change in our culture……physicians are even asking about the model and how to use it for peer review”.

“Thanks for getting Missouri on the right track!”

What We’ve Learned

Into the Future….• In Missouri

– 18-month follow-up assessment – Integration into other MOCPS Projects

• EMS PSO• People, Priorities, Learning Together

– Certified Trainers– Ongoing Board of Nursing training– Potential for other provider groups– Consumer understanding

• Nationally – Federal legislation– National expansion – Health reform implications

Just Culture – What’s Is It All About?• Knowing the risks

– Investigating the source of error and at-risk behaviors– Turning events into an understanding of risk– Creating a learning culture

• Designing safe systems

• Facilitating safe choices– Consoling the human error – addressing the system– Coaching the at-risk behavior – encouraging behavior change– Punishing the reckless behavior - appropriately

Our Just Culture Celebration – April 2009

THANK YOU!QuestionsMissouri Center for Patient Safetywww.mocps.org573-636-1014Becky Miller, MHA, CPHQ, FACHE – bmiller@mocps.org